Abstract
Purpose
Effects of suture preparation on graft contamination remain unknown in anterior cruciate ligament reconstruction (ACLR). This study aimed to evaluate the incidence of allograft contamination at different time points of graft preparation and investigate differences in contamination between different sites of the allografts.
Methods
Fourteen hamstring tendon (HT), 9 quadriceps tendon (QT), and 9 bone–patellar tendon–bone (BTB) allografts were harvested, sterilised, and stored following routine procedures. Graft suture preparation was performed with baseball stitching for soft tissue and bone drilling for bone plug. The time was recorded simultaneously. The graft was kept moist in a standard operating room environment for 30 min after the initiation of preparation. The specimens were obtained from the middle and both ends of each graft for culture at three different time points: pre-suturing, post-suturing, and 30 min after the initiation of preparation. A total of 192 specimens were transferred to the microbiology laboratory for culture, identification, and semi-quantitative assessment. Culture results were classified as negative, poor, and abundant based on the extent of growth. Contamination level was recorded as low or high corresponding to culture results of poor or abundant.
Results
The duration of suture preparation was 348, 301, and 246 s for HT, QT, and BTB (P = 0.090). The specimens had a positive culture rate of 41/192 (21.4%), of which 21 were from the ends and 20 from the middle. More positive samples with abundant bacterial growth were detected from the ends than from the middles post-suturing (7/8 vs. 1/7, P = 0.010) and at 30 min (6/11 vs. 0/11, P = 0.012). The total graft contamination rate was significantly higher at 30 min (19/32, 59.4%) than pre-suturing (4/32, 15.6%) and post-suturing (9/32, 28.1%) (P < 0.001). The contamination rate with abundant bacterial growth was higher post-suturing (7/32, 21.9%) than pre-suturing (0%). No statistically significant differences were found among the three types of allografts.
Conclusion
The contamination rate increases significantly at 30 min compared with pre-suturing and post-suturing. Suture preparation may have introduced the high-level contamination, to which the ends of the graft were more prone than the middle. Therefore, routine prophylactic decontamination after suture preparation should be considered, especially for the ends of the grafts.
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Abbreviations
- ACLR:
-
Anterior cruciate ligament reconstruction
- HT:
-
Hamstring tendon
- QT:
-
Quadriceps tendon
- BTB:
-
Bone–patellar tendon–bone
- SM :
-
Sample from the middle
- SE :
-
Sample from each end
- ICC:
-
Intra-class correlation coefficients
References
Aganovic A, Cao G, Fecer T, Ljungqvist B, Lytsy B, Radtke A et al (2021) Ventilation design conditions associated with airborne bacteria levels within the wound area during surgical procedures: a systematic review. J Hosp Infect 113:85–95
Agarwalla A, Gowd AK, Liu JN, Garcia GH, Bohl DD, Verma NN et al (2019) Effect of operative time on short-term adverse events after isolated anterior cruciate ligament reconstruction. Orthop J Sports Med 7:2325967118825453
Alomar AZ, Alfayez SM, Somily AM (2018) Hamstring autografts are associated with a high rate of contamination in anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 26:1357–1361
Badran MA, Moemen DM (2016) Hamstring graft bacterial contamination during anterior cruciate ligament reconstruction: clinical and microbiological study. Int Orthop 40:1899–1903
Bansal A, Lamplot JD, VandenBerg J, Brophy RH (2017) Meta-analysis of the risk of infections after anterior cruciate ligament reconstruction by graft type. Am J Sports Med 46:1500–1508
Barbier O, Danis J, Versier G, Ollat D (2015) When the tendon autograft is dropped accidently on the floor: a study about bacterial contamination and antiseptic efficacy. Knee 22:380–383
Baron JE, Shamrock AG, Cates WT, Cates RA, An Q, Wolf BR et al (2019) Graft preparation with intraoperative vancomycin decreases infection after ACL reconstruction: a review of 1,640 cases. J Bone Joint Surg Am 101:2187–2193
Bartek B, Winkler T, Garbe A, Schelberger T, Perka C, Jung T (2021) Bacterial contamination of irrigation fluid and suture material during ACL reconstruction and meniscus surgery: low infection rate despite increasing contamination over surgery time. Knee Surg Sports Traumatol Arthrosc. https://doi.org/10.1007/s00167-021-06481-3
Boddapati V, Fu MC, Nwachukwu BU, Camp CL, Spiker AM, Williams RJ et al (2020) Procedure length is independently associated with overnight hospital stay and 30-day readmission following anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 28:432–438
Bohu Y, Klouche S, Sezer HB, Herman S, Grimaud O, Gerometta A et al (2020) Vancomycin-soaked autografts during ACL reconstruction reduce the risk of post-operative infection without affecting return to sport or knee function. Knee Surg Sports Traumatol Arthrosc 28:2578–2585
Brophy RH, Wright RW, Huston LJ, Haas AK, Allen CR, Anderson AF et al (2021) Rate of infection following revision anterior cruciate ligament reconstruction and associated patient- and surgeon-dependent risk factors: retrospective results from MOON and MARS data collected from 2002 to 2011. J Orthop Res 39:274–280
Brophy RH, Wright RW, Huston LJ, Nwosu SK, Group MK, Spindler KP (2015) Factors associated with infection following anterior cruciate ligament reconstruction. J Bone Joint Surg Am 97:450–454
Camarda L, Giambartino S, Lauria M, Saporito M, Triolo V, D’Arienzo M (2016) Surgical time for graft preparation using different suture techniques. Muscles Ligaments Tendons J 6:236–240
Carroll AM, Kim KG, Walters ET, Phillips BK, Singh B, Dekker PK et al (2021) Glove and instrument changing to prevent bacterial contamination in infected wound debridement and closure procedures: a prospective observational study. Int Wound J 18:664–669
Cohen SB, Sekiya JK (2007) Allograft safety in anterior cruciate ligament reconstruction. Clin Sports Med 26:597–605
Díaz-de-Rada P, Barriga A, Barroso JL, García-Barrecheguren E, Alfonso M, Valentí JR (2003) Positive culture in allograft ACL-reconstruction: what to do? Knee Surg Sports Traumatol Arthrosc 11:219–222
Everhart JS, DiBartola AC, Dusane DH, Magnussen RA, Kaeding CC, Stoodley P et al (2018) Bacterial deoxyribonucleic acid is often present in failed revision anterior cruciate ligament reconstructions. Arthroscopy 34:3046–3052
Flanigan DC, Everhart JS, DiBartola AC, Dusane DH, Abouljoud MM, Magnussen RA et al (2019) Bacterial DNA is associated with tunnel widening in failed ACL reconstructions. Knee Surg Sports Traumatol Arthrosc 27:3490–3497
Gavriilidis I, Pakos EE, Wipfler B, Benetos IS, Paessler HH (2009) Intra-operative hamstring tendon graft contamination in anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 17:1043–1047
Gobbi A, Karnatzikos G, Chaurasia S, Abhishek M, Bulgherhoni E, Lane J (2016) Postoperative infection after anterior cruciate ligament reconstruction. Sports Health 8:187–189
Gowd AK, Liu JN, Bohl DD, Agarwalla A, Cabarcas BC, Manderle BJ et al (2019) Operative time as an independent and modifiable risk factor for short-term complications after knee arthroscopy. Arthroscopy 35:2089–2098
Guelich DR, Lowe WR, Wilson B (2007) The routine culture of allograft tissue in anterior cruciate ligament reconstruction. Am J Sports Med 35:1495–1499
Hantes ME, Basdekis GK, Varitimidis SE, Giotikas D, Petinaki E, Malizos KN (2008) Autograft contamination during preparation for anterior cruciate ligament reconstruction. J Bone Joint Surg Am 90:760–764
Hulet C, Sonnery-Cottet B, Stevenson C, Samuelsson K, Laver L, Zdanowicz U et al (2019) The use of allograft tendons in primary ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 27:1754–1770
Khan M, Rothrauff BB, Merali F, Musahl V, Peterson D, Ayeni OR (2014) Management of the contaminated anterior cruciate ligament graft. Arthroscopy 30:236–244
Kraus Schmitz J, Lindgren V, Edman G, Janarv P-M, Forssblad M, Stålman A (2021) Risk factors for septic arthritis after anterior cruciate ligament reconstruction: a nationwide analysis of 26,014 ACL reconstructions. Am J Sports Med 49:1769–1776
Lin KM, Boyle C, Marom N, Marx RG (2020) Graft selection in anterior cruciate ligament reconstruction. Sports Med Arthrosc Rev 28:41–48
Luciano RC, Macedo ÍS, Pereira RHN, Pereira DB, Luciano DV (2020) Intraoperative graft decontamination during ACL reconstruction surgery. Rev Bras Ortop (Sao Paulo) 55:410–414
Maletis GB, Inacio MC, Reynolds S, Desmond JL, Maletis MM, Funahashi TT (2013) Incidence of postoperative anterior cruciate ligament reconstruction infections: graft choice makes a difference. Am J Sports Med 41:1780–1785
Nakayama H, Yagi M, Yoshiya S, Takesue Y (2012) Micro-organism colonization and intraoperative contamination in patients undergoing arthroscopic anterior cruciate ligament reconstruction. Arthroscopy 28:667–671
Offerhaus C, Balke M, Hente J, Gehling M, Blendl S, Hoher J (2019) Vancomycin pre-soaking of the graft reduces postoperative infection rate without increasing risk of graft failure and arthrofibrosis in ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 27:3014–3021
Pérez-Prieto D, Perelli S, Corcoll F, Rojas G, Montiel V, Monllau JC (2021) The vancomycin soaking technique: no differences in autograft re-rupture rate. A comparative study. Int Orthop 45:1407–1411
Pérez-Prieto D, Portillo ME, Torres-Claramunt R, Pelfort X, Hinarejos P, Monllau JC (2018) Contamination occurs during ACL graft harvesting and manipulation, but it can be easily eradicated. Knee Surg Sports Traumatol Arthrosc 26:558–562
Perez-Prieto D, Torres-Claramunt R, Gelber PE, Shehata TMA, Pelfort X, Monllau JC (2016) Autograft soaking in vancomycin reduces the risk of infection after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 24:2724–2728
Phegan M, Grayson JE, Vertullo CJ (2016) No infections in 1300 anterior cruciate ligament reconstructions with vancomycin pre-soaking of hamstring grafts. Knee Surg Sports Traumatol Arthrosc 24:2729–2735
Plante MJ, Li X, Scully G, Brown MA, Busconi BD, DeAngelis NA (2013) Evaluation of sterilization methods following contamination of hamstring autograft during anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 21:696–701
Pogorzelski J, Themessl A, Achtnich A, Fritz EM, Wörtler K, Imhoff AB et al (2018) Septic arthritis after anterior cruciate ligament reconstruction: how important is graft salvage? Am J Sports Med 46:2376–2383
Roach R, Yu S, Pham H, Pham V, Virk M, Zuckerman JD (2019) Microbial colonization of subscapularis tagging sutures in shoulder arthroplasty: a prospective, controlled study. J Shoulder Elbow Surg 28:1848–1853
Romano F, Milani S, Gustén J, Joppolo CM (2020) Surgical smoke and airborne microbial contamination in operating theatres: influence of ventilation and surgical phases. Int J Environ Res Public Health 17:5395
Shang X, Wang H, Li J, Li Q (2019) Progress of sterilization and preservation methods for allografts in anterior cruciate ligament reconstruction. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 33:1102–1107
Thaler M, Khosravi I, Lechner R, Ladner B, Coraça-Huber DC, Nogler M (2020) An intraoperative assessment of bacterial contamination on surgical helmets and gloves during arthroplasty surgeries. Hip Int. https://doi.org/10.1177/1120700020963544
Uzun E, Misir A, Ozcamdalli M, Kizkapan EE, Cirakli A, Calgin MK (2020) Time-dependent surgical instrument contamination begins earlier in the uncovered table than in the covered table. Knee Surg Sports Traumatol Arthrosc 28:1774–1779
Varettas K (2013) Culture methods of allograft musculoskeletal tissue samples in Australian bacteriology laboratories. Cell Tissue Bank 14:609–614
Xiao M, Leonardi EA, Sharpe O, Sherman SL, Safran MR, Robinson WH et al (2020) Soaking of autologous tendon grafts in vancomycin before implantation does not lead to tenocyte cytotoxicity. Am J Sports Med 48:3081–3086
Yamakado K (2018) Propionibacterium acnes suture contamination in arthroscopic rotator cuff repair: a prospective randomized study. Arthroscopy 34:1151–1155
Zhang Z, Gao X, Ruan X, Zheng B (2021) Effectiveness of double-gloving method on prevention of surgical glove perforations and blood contamination: a systematic review and meta-analysis. J Adv Nurs 77:3630–3643
Funding
National Key Research and Development Program of China [2018YFC1106200, 2018YFC1106202], and Shanghai Pujiang Program [Grant No.2020PJD041], and Basic Research Program of Shanghai Sixth People’s Hospital (Grants No. ynms202105).
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CW, SZ and JZ contributed to conceptualisation. CW, XZ, YQ and SZ contributed to data curation and experiment manipulation. CW, JC and WS contributed to formal analysis and writing. CW, ZY and JJ contributed to measurement. CX and JX contributed to editing and revising. SZ, GX and JZ were responsible for the project administration and supervision.
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All specimens were obtained from a tissue bank aiming for medical study. Given that this study was carried out as a laboratory study without patient involvement, no ethical approval was required.
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Wu, C., Zhang, X., Qiao, Y. et al. Allograft contamination during suture preparation for anterior cruciate ligament reconstruction: an ex vivo study. Knee Surg Sports Traumatol Arthrosc 30, 2400–2407 (2022). https://doi.org/10.1007/s00167-022-06903-w
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DOI: https://doi.org/10.1007/s00167-022-06903-w